Chief complaint: Sore Throat X 3 days

HPI:

19 y/o female with PMHx of asthma (on albuterol PRN) presents complaining of a sore throat for the last 3 days. She says she feels a “throbbing-like” pain and rates it as a 6/10 and does not radiate anywhere. Patient reports difficulty swallowing both liquids and solids due to the pain and has a poor appetite. Patients voice is muffled and she mentions that she has had fever and chills at home (with a TMAX 103°F). Patient endorses that she went to an urgent care by her house yesterday and had a negative flu/covid/strep test/mono-spot test and was given liquid Tylenol that provided minimal symptomatic relief. Patient denies nausea, cough, vomiting, chest pain, abdominal pain, headache, shortness of breath, or sick contacts.

DDx:

Peritonsillar abscess

Group A Strep throat

Diphtheria

Mononucleosis

Epiglottitis

Past Medical History

Asthma

Immunizations: up to date; Covid vaccine X 3 which includes the booster and took the Flu vaccine back in September 2024 for school

Past surgical history: None

Medications

Albuterol PRN

Allergies

– Shrimp: Food – hives and rash

– Peanuts: Food – hives and rash

Family history

– Father – 52, HTN, alive

– Mother – 49, DM2, alive

– Brother – 25, alive and well

Social History

Patient is living in on the first floor of a third-floor walk-up apartment in Queens, NY with no stairs to get into the building. She lives with her father and mother.

Habits: denies drinking alcohol, smoking cigarettes, or using illicit substance abuse.

Travel: Pt has not traveled recently

Diet: The patient eats what her mother generally makes her which are protein meals with carbohydrates. The patient tries to make salads and has fruits and vegetables as often as possible.

Exercise: Walks around her college campus

Occupation: Patient is a college student at Queens College

Sleep: reports that she sleeps about 6-7 hours a night

Sexual history: Is not currently sexually active and has no history of STI’s

Ancillary Physician: Patient does not have a primary care physician

ROS

General – Admits to fever and chills. Denies fatigue, night sweats, or weight loss

Skin, Hair, Nails – Denies any change in hair texture, excessive dryness or sweating, discolorations, pigmentations, rashes, or pruritus

Head – Denies losing unconsciousness, headache or being lightheaded currently.

Eyes – Denies visual disturbances, blurry vision, fatigue, photophobia, lacrimation, or pruritus.

Nose/sinus – Denies obstruction, discharge, or epistaxis.

Ears – Denies deafness, pain, discharge, tinnitus, or hearing aids.

Mouth/throat – Admits to muffled voice and pain with swallowing. Denies bleeding gums, sore tongue, mouth ulcers, or denture use.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies orthopnea, dyspnea, wheezing, hemoptysis, cyanosis, cough, paroxysmal nocturnal dyspnea.

Cardiovascular system – Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur, chest pain or hypertension.

Gastrointestinal system – Admits to poor appetite. Denies vomiting, pyrosis, flatulence, eructation, flank pain, jaundice, change in bowel habits, constipation, diarrhea, pelvic pain, abdominal pain, or dysphagia

Genitourinary system – Denies incontinence, change in urine color, polyuria, dysuria or nocturia

Menstrual/obstetrical – Denies any abnormalities such as vaginal bleeding, vaginal discharge, vaginal itching, or dyspareunia.

Nervous – Denies weakness, headaches, sensory disturbances, or seizures.

Musculoskeletal system – Denies redness, back pain, arm pain, swelling or arthritis.

Peripheral vascular system – Denies intermittent claudication, trophic changes, varicose veins, peripheral edema, or color changes.

Hematologic system – Denies easy bruising and bleeding, anemia, lymph node enlargement, blood transfusions, or h/o DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Denies helplessness or hopelessness, anxiety, depression, and a history of seeing a mental health professional, lack of interest in usual activities, suicidal ideation, or OCT.

Vital signs:

– BP: L: 114/67 mm/Hg

– Respiratory rate: 18 breaths/min, unlabored

– Pulse: 91 beats/min, regular

– Temperature: 98.8 degrees F (oral)

– O2 sat: 98% room air

– Height: 5’2”

– Weight: 60.8 Kgs

– BMI: 24.5

Physical Exam

General –Female in her late teens is awake, alert, and oriented x 3 and in no acute distress. She is dressed appropriately for the weather and has a good affect and mood.

Skin, Hair, Nails:

Skin – No bruising was noted on the patient. Good turgor. No tenting. Normal body temperature was noted. Non-icteric

Hair – Average quantity and distribution. No nits or lice were seen; no seborrhea was noted

Nails – No clubbing was seen; cap refill was under 2 seconds. No splinter hemorrhages, lesions, swelling nor any beau’s lines were noted. Atraumatic.

Head – Normocephalic, atraumatic and non-tender to palpation.

Eyes – Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctive pink.

Ears – Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge, bleeding, or foreign bodies in external auditory canal AU.

Nose – Symmetrical nares with no masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally. Nasal mucosa pink. No discharge noted on anterior rhinoscopy. Septum midline without any lesions, deformities, or perforation. No foreign bodies.

Sinuses – Non tender to palpation and percussion over bilateral frontal and maxillary sinuses.

Mouth, Pharynx:

Lips – Pink, moist with no cyanosis or masses noted. Non-tender to palpation.

Oral Mucosa – Pink and well hydrated. No masses, lesions or leukoplakia noted.

Palate – Pink and well hydrated. No masses or lesions noted.

Teeth – Good dentition with a couple of filled cavities noted.

Gingivae – Pink and moist. No hyperplasia or masses.

Tongue – Pink, well papillated. No masses, lesions or deviation noted.

Oropharynx – Bilateral enlargement of tonsils with white exudates. Well hydrated. No erythema noted.

Neck – Palpable bilateral cervical lymphadenopathy. Trachea midline. No masses, lesions, or scars noted. Supple and non-tender to palpation. Full range of motion.

Thyroid – Non-tender, no thyromegaly. No palpable nodules nor any bruits noted.

Chest – Symmetrical, no deformities and no trauma noted. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout

Lungs – Symmetrical expansion with respiration. No intercostal retractions, or tenderness. Breath sounds clear to auscultation bilaterally. No rales/wheezes/rhonchi auscultated.

Heart – Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdomen – Non-distended, non-tender to palpation and soft. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No guarding present. No palpable masses or organomegaly. No inguinal hernia. No palpable lymphadenopathy. Costovertebral angles nontender.

Mental status exam: Patient is well appearing, has good hygiene, and is neatly groomed. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory and attention intact.

Neurology: Patient is alert and oriented to name, date, time, and location. Cranial nerves II-XII grossly intact.

Motor/Cerebellar: Full active/passive ROM of all upper and lower extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 of both upper and lower extremities.

Imaging:

CXR: 2 Views – Frontal and lateral. The heart is normal in size. Lungs are clear. There is no pneumothorax or pleural effusion.

CT Neck and Soft Tissue: Soft tissue bilateral palatine tonsillitis; No evidence of peritonsillar abscess

EKG: Normal sinus rhythm

Assessment:

19 y/o female with PMHx of asthma controlled with albuterol PRN presents with a sore throat, fever, and chills for 3 days with difficulty swallowing solids and liquids. On exam patient has bilateral cervical lymphadenopathy, and an oropharynx with bilateral enlargement of tonsils with white exudates. CT Neck shows bilateral palatine tonsillitis.

Plan:

Problem 1: Palatine tonsillitis

• Consult with ENT
• Ampicillin/Sulbactam (Unasyn) IV 3 grams every 6 hours
• IV Dexamethasone IV 8 mg every 8 hours
• IM Ketorolac (Toradol) 30 mg for the pain
• Pureed food and clear liquid diet
• Consult Infectious Disease
• Group A Strep Cx
• EBV serologic and antibody testing
• Diphtheria antibody test
• Respiratory Viral panel
• Blood cultures
• Normal saline drip – 100 ml/hr
• Monitor CBC/LFT

Problem 2: Asthma

• Control with Albuterol PRN

Advanced Directives – Full code only